Peak Behavioral Health Services, LLC

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to ensure that staff followed policy to obtain informed consent for psychotropic medication administration for 3 (Patient [P]2, P3, and P4 out of 3 [P2-P4]) patients reviewed for medication consents. This deficiency could lead to patients and their representatives not being fully involved in their treatment decisions. The findings are: A. Record review of the facility’s policy titled Medication Administration and Process, dated 12/2025, under the section “Informed Consent” it stated, “The Nurse will obtain and witness the patient’s or legal guardian’s written consent to the prescribed medication, documenting via [electronic medical record] or approved downtime form. Verbal consent may be received and documented with verification as evidence by two RN [registered nurse] signatures.” B. Record review of P2’s medical record for admission dated 08/27/25 revealed medication consents were documented as verbal and were not witnessed by two staff members, as required. 1. There were seven medication consents dated 08/27/25 which showed verbal consent was received from the patient’s legal guardian. The forms contained only one staff signature. 2. There were two medication consents dated 08/28/25 which showed verbal consent was received from the patient’s legal guardian. The forms contained only one staff signature. 3. There was one medication consent dated 08/29/25 which showed verbal consent was received from the patient’s legal guardian. The form contained only one staff signature. C. Record review of P3’s medical record for admission dated 08/30/25 revealed medication consents were documented as verbal but were not witnessed by two staff members. 1. There were 10 medication consents dated 08/30/25 which showed verbal consent was received from the patient’s legal guardian. The forms contained only one staff signature. 2. There was one medication consent dated 09/02/25 which showed verbal consent was received from the patient’s legal guardian. The form contained only one staff signature. D. Record review of P4’s medical record for admission dated 01/09/26 revealed medication consents were documented as verbal but were not witnessed by two staff members. 1. There were seven medication consents dated 01/09/26 which showed verbal consent was received from the patient’s legal guardian. The forms contained only one staff signature. 2. There were four medication consents dated 01/10/26 which showed verbal consent was received from the patient’s legal guardian. The forms contained only one staff signature. E. During an interview on 05/20/26 at 10:45 AM with Staff (S) 4, non-clinical, confirmed verbal consent requires two staff witnesses. S4 confirmed a second witness signature was not obtained for P2, P3, or P4.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 54356 Based on record review and interview, the facility failed to ensure diabetic patients received treatment for elevated blood sugars for 2 (Patients (P) 8 and P9 out of 3 [P7-P9]) admitted patients. This deficient practice could lead to a medical emergency requiring a higher level of care and transfer to an acute care hospital. The findings are: A. Record review of the undated facility’s diabetic protocol revealed insulin coverage begins with a blood sugar of 151mg/dL or greater. The protocol included a sliding scale indicating what dose of insulin would be required based on the patient’s blood sugar reading. B. Record review of P8’s blood glucose monitoring and medication administration record (MAR) for the admission dated 05/04/26 revealed the following: 1. On 05/05/26 at 7:36 PM the patient’s blood glucose was 217 mg/dL. There was no documentation of insulin administration according to the MAR, and there was no other documentation addressing the elevated blood glucose reading. 2. On 05/07/26 at 1:10 PM the patient’s blood glucose was 159 mg/dL. There was no documentation of insulin administration according to the MAR, and there was no other documentation addressing the elevated blood glucose reading. C. Record review of P9’s blood glucose monitoring and medication administration record (MAR) for the admission dated 04/15/26 revealed the following: 1. On 04/17/26 at 9:16 PM the patient’s blood glucose was 309 mg/dL. There was no documentation of insulin administration according to the MAR, and there was no evidence explaining why the elevated blood glucose was not treated. 2. On 04/18/26 at 11:33 PM the patient’s blood glucose was 309 mg/dL. There was no documentation of insulin administration according to the MAR, and there was no evidence explaining why the elevated blood glucose was not treated. 3. On 04/21/26 at 6:10 PM the patient’s blood glucose was 459 mg/dL. There was no documentation of insulin administration according to the MAR, and there was no evidence explaining why the elevated blood glucose was not treated. D. During an interview on 05/20/26 at 10:30 AM, Staff (S) 4, non-clinical, confirmed the findings identified in the medical record of P8 and P9.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 54356 Based on interview and record review, the facility failed to ensure that staff followed policy for documenting a patient’s medication refusal for 1 (Patient [P]7 out of 1 [P7]) patient reviewed for medication refusal documentation. This deficient practice could lead to incomplete medical information and compromise the continuity of care. The findings are: A. Record review of the facility’s policy titled, Medication Administration and Process, dated 12/2025, under section “Medication Administration” stated, the patient has the right to refuse medication at any time. The policy further stated the administering nurse must document the refusal in the electronic medical record (EMR) and notify the provider of the refusal. B. Record review of P7’s medical record for the admission dated 12/23/25 revealed Staff (S) 8, clinical, did not document P7’s refusal of the ordered insulin administration on 01/23/26 at 9:06 AM on the Medication Administration Record (MAR) in the EMR, nor is there documentation of provider notification of the refusal. C. During an interview on 05/20/26 at 8:45 AM, S8 confirmed the patient’s medication refusal not documented in the MAR and provider notification not entered in the EMR.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49835 Based on record reviews and interviews, the facility failed to follow the Documentation Standards policy and perform a skin assessment on 1(P[patient] 1) out of 6 (P1 through P6) patients reviewed, after a change in condition. This deficient practice could lead to all patients being admitted to the facility and patients with a significant change, not having a skin assessment. This could lead to skin breakdown, bruises not being identified and infections to open wounds not being cared for in a timely manner. The findings are: A. Review of Policy titled “Documentation Standards” dated 12/2023 Section 3 titled, “Skin Assessment” stated, “Skin assessment will be completed on admission, at a minimum, and after any significant change”. B. Review of the incident log for 08/23/25 revealed an incident where P1 had fallen to the floor while attempting to stand. Review of P1’s medical record revealed there was no skin assessment completed after this incident. C. Review of P1’s medical chart at the facility there is only 1 skin assessment that was completed on admission dated 08/16/25 at 2:00am. Reviewing P1’s medical record it was documented on 08/17/25 at 10:45am, 08/18/2025 at 1:11pm, 08/20/25 at 10:40am, 08/21/2025 at 7:23pm and 08/24/2025 at 10:45am that P1 became agitated with aggression and self harming behaviors and received Zyprexa (Antipsychotic) 15 milligrams intramuscular (administered in a large muscle) shots. On 08/18/25 at 11:12am P1 complained of pelvic (area of the body below the abdomen) pain and Diflucan (antifungal medication) for yeast infection was ordered on 08/18/25. There were no skin assessment after any of these significant changes. D. During an interview with S(Staff)3 (clinical) it was confirmed that a skin assessment was not completed after P1 fell on 08/23/25 and a skin assessment should have been completed. S3 also stated a skin assessment should have been completed after the need for the Zyprexa shots and Diflucan because there were considered changes in condition. E. During an interview S4 (clinical) confirmed that a skin assessment was completed on P1 at admission and there was no further skin assessment during the patient’s admission. F. During an interview with S10 (clinical) it was confirmed that a skin assessment is completed on admission and with any changes. S10 also confirmed that after an incident such as a fall a skin assessment should be completed.”

“DIETS CFR(s): 482.28(b)(2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals. This Standard is not met as evidenced by: 53173 Based on interviews and record reviews, the facility failed to ensure medical staff ordered a diabetic diet for 1 (P[patient]4) out of 6 (P1 through P6) patient files reviewed for compliance with therapeutic diets. This deficient practice could lead to delays in care (such as high or low blood sugar levels requiring medical intervention) and potential patient harm because staff did not meet the dietary needs of the patient. A. During an interview on 09/10/25 at 9:20 am with S(staff)8, clinical, it was confirmed that both medical providers and nursing staff can place requests for patient nutritional consults to the facility dietician. B. During an interview on 09/10/25 at 10:15 am with S(staff)9, clinical, it was reported that if nursing staff realized that a patient’s current diet order did not meet their therapeutic needs then nursing staff must communicate this information to the medical provider to request a dietary order change. C. Record review of P4’s medical chart demonstrates that the Nursing Admission Assessment denoted that the admitting nurse reviewed the referring facility’s information about the patient (page 182) and reviewed all the patient’s home medications (page 183). Both items flagged the patient as a person with diabetes (a chronic disease caused by the body not being able to produce or to use insulin hormone effectively). D. Record review of P4’s medical chart demonstrates that the Nursing Admission Assessment denoted that the admitting nurse included diabetes in the “Consult” portion of the patient’s medical history (page 190). E. Record review of P4’s medical chart demonstrates that the, “Narrative Note”, in the “Nursing Admission Assessment,” states, “Patient reports history of diabetes mellitus ... BS [blood sugar] 105. This has been reported to [provider name], awaiting orders” (page 191). F. Record review of P4’s medical chart demonstrates that the, “Nursing Admission Assessment,” marked the patient for a regular diet rather than a diabetic diet. G. Record review of P4’s medical chart demonstrates that the, “Psychiatric Evaluation,” written by the psychiatric physician denotes in the patient’s medical history that the patient “suffers diabetes mellitus” and the medication reconciliation acknowledges the metformin 500 mg (milligrams) twice a day (page 200). H. Record review of facility’s policy 01/2024, “DS.1.02 Meeting Dietary Needs of All Patients” states: III.1.a. On the admission assessment, the Registered Nurse shall complete nutrition screening and notify the Dietitian if the patient qualifies for a nutrition consult. 2.b.c. Physician’s orders for therapeutic diets shall generate a dietitian consult for patient education. I. Record review of facility’s policy dated 01/2024, “DS.1.07 Nutritional Screen and Assessment” states: I . PROCEDURE: A. At the time of admission, the admitting nurse on each patient completes a Nutritional Risk assessment. B. If the patient scores 10 or greater on the Nutritional Risk Screening a Dietary Consult for Nutritional Assessment is requested and the form is placed in the Registered Dietician box. C. The nutritional screen is done within 24 hours of admission. J. Record review of P4’s medical record does not have a Nutritional Risk Screening completed.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 49835 Based on record reviews and interviews the facility failed to communicate discharge planning with the patient’s representative and the accepting facility of 1(P[patient] 1) out of 6 patients (P1 through P6) reviewed. This deficient practice could lead to the representative and the accepting facility not knowing the discharge instructions and how to care for the patient at discharge. This deficient practice could affect all patients being discharged from the facility, with the care takers not knowing how to care for the patients. The findings are: A. Record review of the facility’s policy titled “Aftercare/Discharge Plan Acute Hospital” dated 01/2025, it states “The facility ensures that each client and as appropriate family has participated in and understands their discharge plan and discharge instructions”. “The Discharge Planner/ Case Manager, or designee addresses discharge planning with the family and client during family therapy sessions and conferences on an ongoing basis. This is documented throughout the course of treatment in the medical record, case management notes.” “The Discharge Planner/ Case Manager or Associate, if appropriate, coordinate discharge planning with the community agency to which the client is referred”. B. Record review of P1’s medical file under, “Communication Log” there was no documentation of communication by the Case Manager or Nurse with the patients guardian or the accepting facility. C. During an interview with S(staff) 10, (clinical) on 09/10/25 at 1:52pm it was confirmed that S10 discharged P1 and did not notify the patients guardian or the accepting facility at discharge. S10 stated that the Case Manager is the staff member to contact the patients guardian / family and the receiving facility when a patient is to be discharged. D. During an interview with S (staff)12, (non-clinical) it was confirmed that communication with patient’s guardian or the accepting facility is documented under the communication log section of the patient’s chart. S12 confirmed there was no documentation of communication in the communication log with the guardian or the accepting facility of P1. Also, at discharge patients nurse is the one to call the guardian and the accepting facility. E. During an interview with P1’s guardian on 09/11/25 at 4:38 pm, the guardian confirmed that there was no notification of discharge and found out P1 was discharged when P1 arrived at the accepting facility. F. During an interview with the Administrator of the accepting facility on 09/08/25 at 1:25 pm, the administrator stated P1 just arrived with no notification from the discharging facility. P1 arrived via a transport company and the facility was not expecting her.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 49844 Based on record review and interview the facility failed to ensure patient was involved in making informed of decisions regarding his or her care by failing to follow the company’s policy on patients informed consents for medications and failing to inform patients of risks of leaving the facility against medical advice (AMA) for 1 (P(patient)1) out of 3 (P1-P3) patients being reviewed . This deficient practice could possibly lead to a violation of a patients right to refuse care. The findings are: Failed to ensure that a patient was involved in care planning: A. Record review of the facility’s policy titled “Medication Administration and Process” dated as revised on 12/2023, under section 6.1 stated “All patients, and/or legal guardians, prescribed a psychotropic medication will be informed of the benefits and risks involved in receiving the prescribed medication.” -Under the section 6.2 stated “ . . .informed consent will be obtained prior to administering psychotropic medication”. -Section 6.5 stated “Medications requiring informed consent: Psychotropic medications . . .” -Section 6.6 stated “The nurse will obtain and witness the patient’s or the legal guardian’s written consent to the prescribed medication . . . “ B. Record review of P1’s medical record revealed the following: - On the form titled Chart Summary revealed P1 was admitted on 05/30/24. -Provider’s note under “Medications” revealed “Fluoxetine 80 mg p.o. at bedtime . . . Abilify 5 mg -p.o.” The note also stated “The patient refused even to sign the consent form.” -The form titled “physician orders” dated 05/31/24 stated to dispense the first dose of Abilify. Indicating for the nurse to dispense the first dispense -The section MAR revealed that P1 was offered the Abilify and the Fluoxetine twice. The fluoxetine was administered on 05/31/24 at 20:42 (8:42 PM) and the Abilify was offered on 05/31/24 at 12:41 PM and on 06/01/24 at 9:42 PM despite the patient’s initial refusal. - The record did not contain any evidence of a consent for the medication in P1’s medical chart for the Abilify and Fluoxetine. The record did not contain any evidence that P1 was educated on the risks and benefits of the Fluoxetine. C. During an interview with S2,clinical administrative staff member on 11/05/24 at 3:45 PM, when asked if a written informed consent is needed for psychotropic medications. S2 confirmed that written informed consent is required for all psychotropic medications. When asked if Abilify and Fluoxetine are considered psychotropic medications. S2 confirmed that they are both considered psychotropic medications. When asked when written consent should be obtained. S2 stated “Prior to the first administration of the medication”. When asked what happens when the patient refuses to sign the consent form S2 explained that the medication will not be administered. Failed to ensure that P1 was able to make informed decisions when leaving AMA: D. Record review of the facility’s policy titled “Request for Discharge Against Medical Advice (AMA)” stated “It is the policy of [name of facility] to insist that clients and families be made aware of the relative risks versus benefits of discontinuing treatment prematurely and against medical advice. . .” E. Record review of the P1’s medical record revealed the following: -The form titled Chart Summary revealed P1 was admitted on 05/30/24. - On 06/01/24, P1 requested to leave the facility against medical advice. - The document titled “Request for AMA Discharge” revealed the risks versus benefits were not documented on the form. - Provider note dated 06/01/24, stated “she has elected to sign out against medical advice.” The record not did not contain any evidence of any attempts to inform the patient or the patients family of any of the risks versus benefits in regards to leaving the facility against medical advice. F. During an interview with P1’s family member on 11/05/24 at 1:50 PM, she confirmed that she was not informed of the risks versus benefits of P1 leaving the facility. G. During an interview with S2, clinical administrative staff member, on 11/14/24 at 3:45 PM S2 confirmed that there was no evidence that the patient was informed of the risks versus benefits of signing out AMA.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 49193 Based on record review and interview the facility failed to transport a patient with a decline in cognition to the correct facility. Patient was left unattended at the wrong facility and should have been escorted to the memory care unit of another facility for 1(P[patient] 1) of 10 (P1-10) patients reviewed for transportation and discharge planning. This deficient practice could lead to serious harm, injury or death of the patient. The findings are: A. Review of the facility’s policy titled, “Driver Transporter Policy” undated stated “The Driver/Transporter is responsible for picking up and transporting clients in a safe and responsible manner. He/she will maintain control of the clients at all times. The clients will be loaded from the curbside of the vehicle.” B. Record review of P1’s Medical Record: 1. Titled “Physician Diagnosis Attestation” indicated, admitting diagnosis is unspecified psychosis (generalized diagnosis is given when an individual has a psychotic episode). Admission date 03/14/24 and release date 03/22/24 [From Facility 1]. 2. Titled “Discharge Summary”, page 2 dated 03/22/2024 stated “Discharge After Care Plan: [Facility 3] in [City] as a place of stay and treatment.” C. During an interview with P1’s daughter in-law on 06/28/2024 at 1:35 PM, she explained that P1’s son received a call from a staff member of facility #2. The staff member explained that the facility #2 had P1 which was not the facility that P1 was to be admitted to. P1 was confused and did not have any belongings. The daughter in-law explained that facility #1 had dropped P1 off at the incorrect facility. On 03/22/24 time unknown P1 began to wander inside the building of facility #2, where she was assisted by a staff member to call a family member. The daughter in-law explained that P1 should have been taken to facility #3. The staff member of facility #2 was able to walk P1 across the street to the correct facility, facility #3. D. Record review of voice recording of a phone call between P1’s son and staff member at facility #2 on 03/22/24 date unknown indicated that P1 had been dropped off at the front door of facility #2 and was left unattended. P1’s son said she was supposed to be transported to the memory care unit (a locked unit for confused patients that require 24 hour supervision for safety) at facility #3. Facility #2’s staff member walked the patient to facility #3. E. During an interview with a staff member from facility #3 on 06/26/2024 at 5:05 PM, stated “We were waiting for transport, and we kept waiting about 45 minutes after expected time. Next thing we know staff member from facility #2 walked in the door with the patient. P1 was very upset and said that she was dropped off outside. The patient was confused and did not know where she was supposed to be. P1 was to be admitted into the memory care unit. Staff member stated “I called the daughter in law, and she said she was going to report it to the state. I was trying to get P1 to settle down and took her to have a smoke. . . . .3/22/24 at 1:12 PM it was documented in my journal that [P1] was dropped off at wrong facility.” F. During an interview with a staff member from facility #2 on 07/02/2024 at 2:53 PM, stated “woman was dropped off outside of our community literally at the very front. She walked and said I’m here to sign in . . . What was frustrating was that they literally dropped her off. We got her fed and something to drink. She kept saying she wanted to get hold of her son. She was extremely confused and had some type of cognitive decline. . . Finally, I was able to get a hold of son. He confirmed that P1 was supposed to get admitted into [name of facility #3] Memory Care Unit. P1 did not have any medical records with her, she was saying I’m scheduled to get married to a superstar. It was obvious she was confused. I personally walked her to [Facility #3] and waited. I tried reaching out to [Facility #1] administrator and left several messages.””

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 46375 Based on record review and interview the facility failed to meet the Condition of Participation to ensure patients are discharged with the accurate medication list for continuation of care. The finding are: A. The facility failed to discharge patients with a complete medication list and follow-up appointments. Refer to tag 813”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 46375 Based on record review, observations, and interviews the facility failed to provide patients with accurate information for continuation of care at discharge including but not limited to full medication list and follow-up appointments for 8 (P (Patient) P1, P3, P5, P6, P8, P9, P10 and P11) of 11 (P1-P11) patients. 1. Medication lists were not provided for 8: P1, P3, P5, P6, P8, P9, P10 and P11 patients. 2. Follow-up appointments were missing or incorrect on the “Discharge Continuing Care Plan Assessment” for 2: P1 and P5 patients. These deficient practices could lead to serious harm or death to all patients if correct medication regimen and follow-up appointments are not provided. The findings are: A. Record review of facility policy “Medication Reconciliation” dated 12/2022 stated, “POLICY: In addition, this procedure will ensure, upon discharge or transfer of any client that the next provider of care will have all necessary information regarding medications this client is currently taking. This process includes a comparison of the medications [facility name] provides to those on the list. PROCEDURE: 4. Prior to discharge, the nurse will review the prescribed discharge medication list with the client and provide them with a copy of the medication reconciliation record. B. Record review of facility policy “Discharge of Clients” dated 3/2020 stated, “PROCEDURE: 2.4.4. Medication information to include a copy of the medication reconciliation form” [process of comparing a patient’s medication]. C. Record review of P1’s medical record revealed; 1. Medications listed on the “DISCHARGE MEDICATION RECONCILIATION FINAL”; Aripiprazole 10 mg (Indication: mood), Mirtazapine 7.5 mg (indication: sleep), Oxcarbazepine 300 mg 9 (Indication: Mood), Acetaminophen 325 mg (Indication: for pain), Insulin Lispro 100 units/mL SOLN [solution] (indication: diabetes), Al hydroxide-Mg hydroxide-simethicone 200 mg-200 mg-20 mg/5 mL SUSP (Indication: indigestion), Aspirin 81 mg DRT (indication: CAD [coronary (heart) artery disease]), Atorvastatin 10 mg (indication: Hyperlipidemia [High Cholesterol]), Azithromycin 250 mg (Indication: not noted), Citalopram 20 mg (Indication: not noted), Docusate Sodium 100 mg (Indication: Constipation), Fluticasone nasal 50 mcg/INH SPR 9 (Indication: Not noted), Insulin Glargine 100 units/mL (Indication: Not noted), Insulin Lispro 100 units/mL (indication: diabetes), Levetiracetam 500 mg (Indication: seizures), Lamotrigine 200 mg (Indication: Not noted), Metformin 1,000 mg (Indication: Not noted), Olanzapine 15 mg (Indication: not noted), Omeprazole 20 mg (indication: GERD [acid reflux]), Prednisone 20 mg (Indication: Not noted), Terbinafine 250 mg (Indication: not noted), and Trazodone 100 mg (Indication: not noted). 2. Medications listed on the “Discharge Continuing Care Plan Assessment” under “Discharge Medication Reconciliation” are Aripiprazole Oral 10 mg (Indication: mood), Mirtazapine Oral 7.5 mg (Indication: Sleep), and Oxcarbazepine 300 mg (Indication: mood). Discharge Medication Reconciliation note stated, “I have reviewed and reconciled the patient’s current medication regimen with the prescribed medications to be continued at discharge listed above.” 19 of 22 medications are not listed on the “Discharge Continuing Care Plan Assessment” that are listed on the “Discharge Medication Reconciliation Final”. D. Record review of P3’s medical record revealed; 1. Medications listed on the “DISCHARGE MEDICATION RECONCILIATION FINAL”; Clonazepam 0.5 mg (Indication: anxiety), Escitalopram 20 mg (Indication: Mood), Mirtazapine 7.5 mg (Indication: sleep), Acetaminophen 325 mg (Indication: for pain), Albuterol 90 mcg/INH (Indication: not noted), Chlordiazepoxide 25 mg (Indication: not noted), Fluoxetine 20 mg (Indication: not noted), Fluoxetine 40 mg (Indication: not noted), Acetaminophen-hydrocodone 325 mg-5 mg (Indication: Not noted), Magnesium Hydroxide 8% SUSP (Indication: for constipation), Prazosin 1 mg (Indication: not noted), and Prednisone 20 mg (Indication: not noted). 2. Medications listed on the “Discharge Continuing Care Plan Assessment” under “Discharge Medication Reconciliation” are, Clonazepam 0.5 mg (Indication: anxiety), Escitalopram 20 mg (Indication: Mood), Mirtazapine 7.5 mg (Indication: sleep). Discharge Medication Reconciliation note stated, “I have reviewed the medications listed upon Admission Medication Inventory/Reconciliations forms...I have reviewed and reconciled the patient’s current medication regimen with the prescribed medications to be continued at discharge listed above.” 9 of 12 medications are not listed on the “Discharge Continuing Care Plan Assessment” that are listed on the “Discharge Medication Reconciliation Final”. E. Record review of P5’s medical record revealed; 1. Medications listed on the “DISCHARGE MEDICATION RECONCILIATION FINAL”; Amantadine 100 mg (Indication: Dyskinesia [Uncontrolled involuntary movements]), Benztropine 2 mg (Indication: EPS [Involuntary and uncontrollable movement]), Gabapentin 300 mg (Indication: Neuropathy [damage to the nerves]), Dextromethorphan-Quinidine 20 mg (Indication: pseudobular affect [uncontrollable outbursts of crying or laughing]), Prazosin 2 mg (Indication: Nightmares), Risperidone 2 mg (Indication: Psychosis), Aspirin 81 mg (Indication: CVA [cerebrovascular accident (stroke)]), and Atorvastatin 10 mg (Indication: Hyperlipidemia [high cholesterol]). For this specific patient there is a section titled “DO NOT CONTINUE THESE MEDICATIONS” Under this section Amlodipine 5 mg (Indication: Hypertension [high blood pressure]) is listed. 2. Medications listed on the “Discharge Continuing Care Plan Assessment” under “Discharge Medication Reconciliation” are, Amantadine 100 mg (Indication: Dyskinisia), Benztropine 2 mg (Indication: EPS), Gabapentin 300 mg (Indication: Neuropathy), Dextromethorphan-Quinidine 20 mg (Indication: pseudobular affect), Prazosin 2 mg (Indication: Nightmares), and Risperidone 2 mg (Indication: Psychosis). Discharge Medication Reconciliation note stated, “I have reviewed the medications listed upon Admission Medication Inventory/Reconciliations forms.” There is no instruction for this patient on this form to stop taking Amlodipine 5 mg as noted above. 6 of 9 medications are not listed on the “Discharge Continuing Care Plan Assessment” that are listed on the “Discharge Medication Reconciliation Final”. F. Record review of P6’s medical record revealed; 1. Medications listed on the “DISCHARGE MEDICATION RECONCILIATION FINAL”; Gabapentin 300 mg (Indication: Cravings) Desvenlafaxine 50 mg (Indication: Depression), Lorazepam 2 mg (Indication: Anxiety Secondary to withdrawal symptoms) , and Thiamine 100 mg (Indication: Nutritional supplement). 2. Medications listed on the “Discharge Continuing Care Plan Assessment” under “Discharge Medication Reconciliation” are Gabapentin 300 mg (Indication: Cravings), and Desvenlafaxine 50mg (Indication: Depression). Discharge Medication Reconciliation notes stated, “I have reviewed the medications listed upon Admission Medication Inventory/Reconciliations forms.” There is no instruction for this patient on this form to stop or continue taking Lorazepam 1 mg, and Thiamine 100 mg. G. Record review of P8’s medical record revealed; 1. Medications listed on the “DISCHARGE MEDICATION RECONCILIATION FINAL”; Aripiprazole 15 mg (Indication: Unspecified mood disorder), and Methylphenidate 36 mg (Indication: Attention Deficit Hyperacticity Disorder). For this patient there is also a section titled “DO NOT CONTINUE THESE MEDICATIONS” under this section medications listed are Aripiprazole 300 mg (Indication: Not noted), Aripiprazole 15 mg (Indication: not noted), Methylphenidate 54 mg (Indication: not noted), and Oxcarbazepine 150 mg (Indication: Not noted). 2. Medications listed on the “Discharge Continuing Care Plan Assessment” under “Discharge Medication Reconciliation” are Aripiprazole 15 mg (Indication: Unspecified mood disorder), and Methylphenidate 36 mg (Indication: Attention Deficit hyperactivity disorder). Discharge Medication Reconciliation note stated, “I have reviewed the medications listed upon Admission Medication Inventory/Reconciliations forms...I have reviewed and reconciled the patient’s current medication regimen with the prescribed medications to be continued at discharge listed above.” There is NO instruction for patient to stop taking Aripiprazole 300 mg, Aripiprazole 15 mg, Methylphenidate 54 mg, and Oxcarbazepine 150 mg as noted above. H. Record review of P9’s medical record revealed; 1. Medications listed on the “DISCHARGE MEDICATION RECONCILIATION FINAL”; Bupropion ERT Wellbutrin XL 150 MG (Indication: MDD [Major depressive disorder]) , Topiramate 25 mg (Indication: Unspecified mood disorder), Benzoyl peroxide topical 10% (Indication: Acne), Clindamycin topical 1% (Indication: acne) Tamsulosin 0.4 mg (Indication: Urinary retention), Ibuprofen 600 mg (Indication: Pain), Melatonin 5 mg (Indication: Sleep), Ondansetron 4 mg (Indication: nausea), Benzocaine topical 20% (Indication: Canker sore), and cetirizine 10 mg (Indication: seasonal allergies). For this patient there is a section titled “DO NOT CONTINUE THESE MEDICATIONS” under this section medication listed are Acetaminophen 325 mg (Indication: for pain) Divalproex Sodium ERT 500 mg (Indication: Not noted), and Cetirizine 10 mg (Indication: not noted). 2. Medications listed on the “Discharge Continuing Care Plan Assessment” under “Discharge Medication Reconciliation” are Bupropion ERT 10 mg (Indication: MDD), and Topiramate 25 mg (Indication: Unspecified mood disorder). No Discharge Medication Reconciliation note was on this form. There is no instruction to stop taking Acetaminophen 325 mg, Divalproex Sodium ERT 500 mg, and Cetirizine 10 mg as noted above. I. Record review of P10’s medical record revealed; 1. Medications listed on the “DISCHARGE MEDICATION RECONCILIATION FINAL”; Venlafaxine ERC 75 mg (Indication: Depression), Trazodone 100 mg (Indication: sleep), Oxcarbazepine 300 mg (Indication: mood), and Hydroxyzine Pamoate 50 mg (Indication: anxiety), For this patient there is a section titled “DO NOT CONTINUE THESE MEDICATIONS” under this section medications listed are Acetaminophen 325 mg (Indication: For pain), Aripiprazole 10 mg (Indication: Not noted), Aripiprazole 10 mg (Indication: Not noted), Clonidine 0.1 mg (Indication: withdrawal), Gabapentin 300 mg(Indication: Not noted), Gabapentin 100 mg (Indication: Not noted), Ziprasidone 40 mg (Indication: Not noted), Ibuprofen 600 mg (Indication: for pain), Lithium 300 mg (Indication: Not noted), Methocarbamol 500 mg (Indication: Not noted), Naltrexone 50 mg (Indication: Not noted), Oxcarbazepine 300 mg (Indication: Not noted), Prednisone 10 mg (Indication: Not noted), and Quetiapine 50 mg (Indication: Not noted). 2. Medication reconciliation form states “none” on Discharge Continuing Care Plan Assessment. There is no instruction to stop or continue taking the medications listed above given to the patient. J. Record review of P11’s medical record revealed; 1. Medications listed on the “DISCHARGE MEDICATION RECONCILIATION FINAL”; Aripiprazole 5 mg (Indication: Anxiety), Prazosin 2 mg (Indication: Flashbacks), Acetaminophen 325 mg (Indication: For pain), Aripiprazole 2 mg (Indication: Not noted), Ascorbic Acid 250 mg (Indication: Supplement), Atenolol 50mg (Indication: Not noted), Azelastine Nasal 137 mcg/INH (Indication: Not noted), Benztropine 0.5 mg (Indication: Not noted), Buspirone 10 mg (Indication: Not noted), Celecoxib 200 mg (Indication: Not noted), Cephalexin 500 mg (Indication: Not noted), Cholestyramine 4 g/9 g powder (Indication: Not noted), Duloxetine 20 mg (Indication: Not noted), Levocetirizine 5 mg (Indication: Not noted), Levothyroxine 150 mcg(Indication: Not noted), Levothyroxine 100 mcg (Indication: hypothyroidism [low thyroid horomone]), Lisinopril 10 mg (Indication: Not noted), Mirtazapine 7.5 mg (Indication: Not noted), Multivitamin with Iron (Indication: Nutritional supplement), Naproxen 500 mg (Indication: Not noted), Oxcarbazepine 150 mg (Indication: Not noted), Prednisone 20 mg (Indication: Not noted), Risperisone 0.5 mg (Indication: Not noted), Spironolactone 25 mg (Indication: Hypertension), and Topiramate 25 mg (Indication: Not noted). 2. Medications listed on the “Discharge Continuing Care Plan Assessment” under “Discharge Medication Reconciliation” are Aripiprazole 5 mg (Indication: Anxiety), and Prazosin 2 mg (Indication: Flashbacks). Discharge Medication Reconciliation notes stated, “I have reviewed the medications listed upon Admission Medication Inventory/Reconciliations forms.” No other medications listed. 23 of 25 medications are not listed on the “Discharge Continuing Care Plan Assessment” that are listed on the “Discharge Medication Reconciliation Final”. K. During an interview on 12/07/2023 at 11:30 AM with Staff (S) 5, Assistant Director of Nursing, confirmed that a “Discharge Medication Summary for Patient” is not provided to patients, it can be printed, it’s not part of our policy to print that for every patient. The nurse will explain any of the medications that they come in with. S5 stated that they don’t feel that it is dangerous and is assumed that the patient will continue taking medications not listed on the “Discharge Continuing Care Plan Assessment. L. During an Interview with S6, Nursing supervisor, on 12/07/2023 at 11:00AM, S6 confirmed the only thing the patient is sent home with is the “Discharge Continuing Care Plan Assessment” No other forms are sent home with the patient. M. Observation of the discharge for P11, on 12/07/2023 at 1:10 PM, verified the only form given to the patient was the “Discharge Continuing Care Pan Assessment.” No other medication lists were given with the patient. N. Record review of facility policy “Case Management Discharge Planning” dated 10/1999 stated, “Procedure: 3. Clinical/Nursing Staff proceed with discharge planning activities in a timely manner. Discharge planning activities are identified in two categories: 3.2. Clinical and Utilization Management Staff are responsible for disposition and aftercare activities related to the planning and arranging of services necessary to support the client’s participation in the treatment process and in the aftercare plan.” O. Record review of facility policy “Discharge of Clients” dated 3/2020 stated, “PROCEDURE: 2.4.3. Follow-up instructions.” P. Record review of P1’s “Discharge Continuing Care Plan Assessment” showed a follow-up appointment for Tuesday 08/15/2023 and patient was discharged on Wednesday 08/16/2023. Q. Record review of P5 “Discharge Continuing Care Plan Assessment” showed a follow up appointment with no date or time listed. R. During an interview on 12/08/2023 at 4:08 PM with S11, Lead Case Manager, confirmed case managers are responsible for discharge planning and ensuring follow up appointments are scheduled prior to a patient being discharged. S11 stated, “Rule of thumb, we have to by law get them an appointment for discharge. If you’re still here on the date of the discharge, we have to change the appointment. S11 confirmed that there should not be any reason an appointment is not scheduled.”